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SAN JOAQUIN COUNTY (CC. y ENVIRONMENTAL HEALTH DEPARTMENT LOP �$ .t 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION p� Telephone:(209) 468-3454 Fax:(209) 468-3433 Web:www.siciov.org/ehcf UNIT IV °- RECEIVED WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FEB $ 1 2012 Application Is hereby made to San Joaquln County for a permit to construct and/or Install the work described. This application Is made In compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departm11Wao MENTAL HEALTH Site Location rC�2 _�a s!4 D- Cross Street G. LDLCISc- AyL, city_LAnjo r12 Zip. Cl S 50 APf Lt Property [ Owner 1 Q• S)r✓I F L.0 7- Address J fe d �W-LUO X� City LA jlAw�Zip 7 S v Phone ek•l. �,Cj 9.j C-57 Contractor CA:Y-&'D(-_•1 ' Address City[l AAkNJ �L� �Ic D Phone �/ b�tS, I Fi j Consultant/Sub Cntr.Lf, a C)+- _ Address ,lAjCG I OCity�( V I L4 6 LIc Phone X 16 �96 6320 Billable Party• 'A-oIS _ Address IgIO QOGILY P,04,1, Do entiV&t:6 Zlpj�_Phone.. �I� �,a GIS Coordinates:X i f• 'U�E I Y '- �.2/- 2 1 CONSTRUCTION WORK TO BE PERFORMED: NEtI{I ELLlBORING(CPT,GEOPROBE,HYDROPUNCH HANG-AUGER,OTHER) OIL BORING IDs ❑❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING HOLLOW STEM DIA.OF BOREHOLE _ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: —O EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 1 G TREMIE TYPE TO BF USED: ❑AUGERS ❑HOSC EkIPE ,Z-%SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes b(No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(I.e.Air Smraa.Ozones❑HAND AUGER GROUT SPECIFICATIONS l I C(0'1 FN I - _E]OTHER: ❑OTHER: APPROX.BORING DEPTH i' El BOLTED TRAFFIC BOX OR ❑STOVE PIP[ CONDUCTOR CASING❑No❑Yes:Casing Dla: Casing Depth: Boring Dta: COMMENTS: (,AC,N SCI(_ n,(V—I&;l� ru.L = 4- G.t.. 62Ngnnds__ NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHIMAT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT _ WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT)_ _F I BELOW SURFACE COMMENTS — 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I h ve prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regula tlo s,and al p licable California Laws. Signed _ Title/Company Pro Sc./AJZC,1Dz'S, c(•S, =is Print Name Seott Agtcternar3 Date 2-2o-12- DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE PITE 4DDRESS WORK PLAN DATED U'3 —�. APPLICATION ACCEPTED BY DAT-i D AREA GROUT INSPECTION BY _ -_ FINAL INSPECTION BY DAT4 LO[Z DESTRUCTION INSPECTIO BY DAT __ COMMENTS/CONDITIONS: y 1 '}moo S ;Z�z (-yco ACCOUNTING ONLY: AID# FAC# /// PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# _ tr/• s $125 x L-- --- 7_ L✓��/J�S - =2R# `� 0l5 C-57__ -• WC _WAIVER___ C57 LEITER OF AUTHORIZATION TO SIGN PERMIT -� ENCROACHMENT DOC._-__s_